Outcome

Discharges with a principal diagnosis of community acquired bacterial pneumonia per 100,000 population, age 18 or older. Excludes sickle cell or hemoglobin-S admissions, other indications of immunocompromised state admissions, obstetric admissions, and transfers from other institutions.

[NOTE: The software provides the rate per population. However, common practice reports the measure as per 100,000 population. The user must multiply the rate obtained from the software by 100,000 to report admissions per 100,000 population.]

The percentage of members 18-75 years of age with diabetes (type 1 and type 2) whose most recent LDL-C test is <100 mg/dL during the measurement year.

The CAHPS® Nursing Home Survey: Long-Stay Resident Instrument is an in-person survey instrument to gather information on the experience of long stay (greater than 100 days) residents currently in nursing homes. The Centers for Medicare & Medicaid Services requested development of this survey, and can be used in conjunction with the CAHPS Nursing Home Survey: Family Member Instrument and Discharged Resident Instrument.

The percentage of patients 18-85 years of age with serious mental illness who had a diagnosis of hypertension (HTN) and whose blood pressure (BP) was adequately controlled during the measurement year.

0-100 measure of cross-cultural communication related to patient-centered communication, derived from items on the staff and patient surveys of the Communication Climate Assessment Toolkit

This outcome measure estimates the percentage of Inpatient Rehabilitation Facility (IRF) Medicare patient stays that meet or exceed an expected discharge function score. The expected discharge function score is a risk-adjusted estimate that accounts for patient characteristics. The measure includes patients who are 18 years of age or older and the timeframe for the measure is 12 months.

This outcome measure estimates the percentage of Long-Term Care Hospital (LTCH) patient stays that meet or exceed an expected discharge function score. The expected discharge function score is a risk-adjusted estimate that accounts for resident characteristics. The measure includes patients 18 years of age or older and the measure timeframe is 12 months.

This outcome measure estimates the percentage of Medicare Part A skilled nursing facility stays that meet or exceed an expected discharge function score. The expected discharge function score is a risk-adjusted estimate that accounts for resident characteristics. The measure includes patients who are 18 years of age or older and the measure timeframe is 12 months.

This outcome measure estimates the percentage of Home Health (HH) Medicare patients (18+) who meet or exceed an expected discharge function score over a 12-month period.

The expected discharge function score is a risk-adjusted estimate that accounts for patient characteristics.

This is an ACO-level measure of days at home or in community settings (that is, not in acute care such as inpatient hospital or emergent care settings or post-acute skilled nursing) among adult Medicare Fee-for-Service (FFS) beneficiaries with complex, chronic conditions who are attributed to ACOs participating in the ACO REACH model. The measure includes risk adjustment for differences in patient mix across ACOs, with an additional adjustment based on patients’ risk of death.